mommy.19

The unna boot contains sorbitol (osmotic diuretic), glycerin (moisturizer), and zinc oxide-aka diaper cream (as a skin protectant). One layer is sufficient to compress and draw fluid from the extremities-if needed more kerlix gauze wrap can be applied if the patient is HEAVILY exudating for absorbency, however this should hopefully be managed by educating the patient on elevation of the BLE above the level of the heart when not ambulating. I have seen people lose toes over unna boots being applied incorrectly (it was done more than one time in a row to the pt, who had diabetic neuropathy and could not feel the ischemia in the toes). I would definitely have a knowledgeable person instruct you on the correct method of application. And remember, just because someone is an LPN, RN or even a WOCN, doesn't mean they automatically know how to do this. I had a WOCN once show me to wrap from the knee DOWN! Anyhow, one of the only reasons that more than one unna boot would need to be applied is if the pt's leg is too long, and in that case the second unna boot roll would need to start about 2-3 wraps below the first so that compression can be continued consistently; this also applies if more coban is needed over the kerlix gauze layer, start 2-3 wraps below where the last one ended. Hope this helps!

We use unna boots for many people with venous stasis ulcers or just plain edematous, "weepy" legs. Unna boots are NOT, by manufacturing specifications, indicated for compression, however when physicians write, "unna boots to BLE for compression" this is acceptable, and is the most common use in my experience. If any dressing is placed under an unna boot it would need to be something that can remain intact for the duration the boot is left on (sounds like common sense but sometimes it isn't). We use Xcell AM covered with adaptic if the wound is dry or has any type of eschar, or just plain adaptic. Then, the unna boot is applied as explained by ktrn2b, from the base of the toes to about two finger widths below the popliteal space. Some instructions will direct you to apply the boot in a figure 8 type fashion, however this can be dangerous if another nurse who is not familiar with the process removes this unna boot to apply another and attempts to repeat the figure 8. Any gaps left in the boot will trap the edema and may cause more ulcerations or tissue death. An important factor to consider is the pt's ABI--we normally will not compress anyone with less than 0.8 or more than 1.2. We normally use a dressing as described above under the unna boot on any ulcers, followed by the unna boot itself with a 75% overlap on each wrap, then kerlix gauze and finally coban. The kerlix will absorb the exudate that the sorbitol in the unna boot pulls away and the coban will keep the compression of the unna boot in place until removed.

I agree with the consensus here, adaptic or mepitel one over the wound and maybe a gauze wrap like conform or kerlix---duoderm is waaaaayyyy too adherent for fragile steroid-like skin.

Well, hydrogel is for wounds that are small to NO exudate, and is amorphous so it can (and likely will) macerate healthy periwound even if used on a wound with a dry bed. So, it is not likely the person changing the dressing that is causing this maceration. The wound needs something that is appropriate for it's specific level of exudate. CarreBarre listed very pertinent questions and I would definitely address these. I would discontinue the hydrogel immediately if it were my pt. Just my 2 cents!

Hi Coco, Many things could be preventing the wound from healing including low protein levels, is the pt diabetic or on any immune suppressants? Does the pt smoke? Offloading the area is the number 1 priority with a decubitus, then pinpointing any aggravating factors. Is it infected? How often is the dressing being changed? *Mesalt is generally used for enzymatic debridement and is not sparing to viable periwound tissue, i.e. if the mesalt touches viable tissue it will chew it up just as it would do to slough or fibrin. *If the wound is not progressing after about a month I'd probably change product or try to find any underlying problems aforementioned such as infection, low protein levels, something from the pt's H&P. *Silver nitrate is used to treat hypergranulation and sometimes used in place of surgical or mechanical debridement for "chronic granulation tissue" or the pinkish, slick looking (for lack of a better description) tissue around a chronic wound. I find that this is handy when the patient is not having serial debridements by a physician to mechanically remove the nonviable tissue, but ensure that the Silver Nitrate is deactivated by NS after it is applied or it will continue to cauterize the tissue. Hope this helps a little! :)

For something that is causing significant pain, my question would be is the wound infected? Also, if it is on the patient's buttock I would use an offloading type of dressing, maybe like Tielle light border, mepilex border, duoderm, or even hydrophillic foam with a border dressing over it to cushion it. I think it is a little silly for the nursing home to not want a wound dressed, even if it is covered with something not medicated and non adherent just to protect/potentially lower bioburden. And also, if it makes the patient feel better to place a dressing on it, they're hospice for goodness sake, do what you do best and comfort the patient :)

RiverNurse, Given that the etiology of a decubitus ulcer, one could form almost anywhere. However, without seeing this wound I am guessing that someone has stated the etiology of this wound incorrectly either by accident (did not know what they were looking at) or purposefully did so to avoid repercussions. A skin tear -generally- presents more as a jagged looking rip, not what you're describing. It would be difficult, in my opinion, again, without having seen the actual patient, for someone to have a skin tear in that location. Does the periwound blanch at all? does the patient have any other decubitii that appear similar to this or any other skin tears that resemble it? Sorry, I seem to only have more questions for you :)

We apply unna boots in our wound clinic on a daily basis, and usually place a dressing on any ulcerated areas that is deemed appropriate to be left on for up to a week, such as xcell covered with adaptic, or aquacell AG, I have even used santyl on some sloughy venous stasis ulcers under an unna boot and left it intact for a week with great results.

Only last fall the clinical instructor in a local ICU showed us the importance of being able to assess things in more than one way, i.e. being able to palpate the PMI and derive an apical HR in this way. Now, she said, 99/100 you're going to be using a stethoscope, but there may be a time when it is better to palpate the apical and the radial simultaneously in lieu of listening to one and palpating the other. Just my

I personally LOVE corrections nursing. It's a very different environment (to state the obvious) and you have to really enjoy what you're doing. In my opinion, my personality type jives with this type of position a lot better than many hospital "unit" positions (though my other job is in a Neuro Trauma ICU). I'd advise to go what you're interested in, and if it is an issue of having a secure job, take the one you KNOW you will get.

The only way to "Accelerate" the program is to go to an institution that offers an accelerated program, like OU (13 months for your BSN, but it requires a previous bachelor's degree). TCC is a 2 year, ADN program that can be completed either full time for the 2 years or half time for 3 years. Tulsa Tech and Green Country Technology Center have LPN programs I believe, and you are also eligible at the halfway point of RN school (in most schools depending upon timing and curriculum) to obtain equivalency through to board to sit for your LPN license.

I work as an LPN for an agency in Tulsa, and the LTC pay ranges from 22.50-26.50 depending on shift and location. I live in the Jenks school district and I absolutely love Jenks. I feel like it is the only place left around Tulsa besides Bixby that isn't a trash heap. They are building some brand new apartments in Jenks as well and it is right by the turnpike to go to either hwy 75 or to 169, which will get you anywhere. Most hospitals will hire LPN's for med-surg, especially St. Francis (61st and yale). They have LPN job openings at this time I believe, also LTC will always take LPNs, but it's hard and unforgiving work. Apts around Jenks for 2 bed are around $800 if that helps.

It's pretty much shadowing an RN, learning the duties of the particular area in which you're externing, learning skills, developing assessment skills, etc. Pay is roughly that of a CNA (in Tulsa at least is about the same). If you aren't in classes, like for the summer, they'll have you on a two -three 12/hr shift schedule (if your area or unit operates on 12 hour shifts that is). However, most extern programs for the summer have cutoff deadlines to apply in March or April. Some may take externs on the fly but for mine, I had to apply as if it were for an actual position at the hospital (applied online), then the called for an interview, etc.

Program has been great, busy, difficult to manage at times but I'd never take it back to do anything else. Clinicals are a little shifty, just as disorganized as TCC sometimes but it all works out in the end. They want the reputation, and they want hospitals to WANT OU grads. I know places that see people are from TCC and they whisper "oh crap". I mean, I know it is not indicative of the large percentage of people that go there but it could definitely be a reflection of the faculty and those that govern the program. Many places will not allow TCC to do clinicals at their facility anymore.

Just had to give a shout out for the OU Tulsa admission faculty/advisors, they love and want to help you! :) Sorry about all the bad luck with TCC